Neurosurgery clinics of North America
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Neurosurg. Clin. N. Am. · Apr 1992
ReviewUse of antimicrobial agents to treat central nervous system infection.
When dealing with infections of the central nervous system (CNS), the clinician is often faced with a daunting diagnostic and therapeutic challenge. The clinical presentation can vary from an insidious course that allows time for a full diagnostic examination to fulminant catastrophic events that require immediate therapeutic intervention. ⋯ Clinical experience and scientific investigation have laid the basis for rational empiric antimicrobial therapy of CNS infection. The role of antibiotics in the treatment of CNS infections is reviewed and updated, emphasizing current rationale for empiric therapy as well as the proper use of specific antibiotics for specific pathogens.
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Suppuration involving the epidural and subdural spaces is a rare occurrence in modern neurosurgical practice. Early diagnosis and appropriate treatment of infections of the dural spaces may avert the high incidence of neurologic disability and death traditionally associated with them, however. Prompt neurosurgical intervention in the treatment of these lesions has been the standard with which all other therapies have been compared.
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Neurosurg. Clin. N. Am. · Jan 1992
Charged-particle radiosurgery for intracranial vascular malformations.
Heavy charged-particle radiation has unique physical characteristics that offer several advantages over photons and protons for stereotactic radiosurgery of intracranial AVMs. These include improved dose distributions with depth in tissue, small angle of lateral scattering, and sharp distal fall-off of dose in the Bragg ionization peak. Under multi-institutionally approved clinical trials, we have used stereotactic helium-ion Bragg peak radiosurgery to treat approximately 400 patients with symptomatic, surgically inaccessible vascular malformations at the UCB-LBL 184-in synchrocyclotron and bevatron. ⋯ The first 230 patients have been evaluated clinically to the end of 1989. Using the clinical grading of Drake, about 90% of the patients had an excellent or good neurologic grade, about 5% had a poor grade, and about 5% had progression of disease and died, or died as a result of unrelated intercurrent illness. Neuroradiologic follow-up to the end of 1989 indicated the following rates of complete angiographic obliteration 3 years after treatment: 90% to 95% for AVM treatment volumes less than 4 cm3, 90% to 95% for volumes 4 to 14 cm3, and 60% to 70% for volumes greater than 14 cm3.(ABSTRACT TRUNCATED AT 400 WORDS)
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If return to work is part of the expected outcome, more and more data indicate that medical care alone does not hold the key to providing success. Our modern physical treatments may seem a humane alternative to no treatment, but they have not been proven to significantly alter the natural course of back problems. Even the results of strongly indicated surgical treatment differ little from doing nothing at all after a 4-year period. ⋯ This humane approach to care has evolved from common frustrations of dealing with patients with back problems, observations in the third world, and information gained from scientific studies. Medical pain, and physical models alone are unsuccessful. To be humane and successful, we can no longer ignore the nonphysical factors that can, and do, influence patients' responses to physical treatment, especially when return to work is part of the expected outcome.
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Because most people in the United States have occasional back pain, demand for the treatment of back pain is widespread. Yet, few treatments have proven to be more effective than placebo therapy. We examine patterns of treatment that have emerged in the absence of definitive treatment. ⋯ Average lengths of stay for surgical and nonsurgical low back pain hospitalizations decreased. We explore why, in the instance of low back pain surgery, change was resisted, whereas, in the instance of average lengths of stay, change was accepted. In view of why change may be resisted or accepted, we discuss interventions designed to change physicians' practice style.